ppt chapter031

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Introduction to Clinical Pharmacology

Chapter 31-Skeletal Muscle Relaxants and Drugs

Used to Treat Bone and Joint Disorders


Bone Resorption Inhibitors: Bisphosphonates: Actions and Uses Bone Resorption Inhibitors: Bisphosphonates: Actions and Uses • Actions:

– Act primarily on bone by inhibiting normal and abnormal bone resorption

• Uses:

– Osteoporosis in postmenopausal women and men

– Hypercalcemia of malignant diseases

– Paget’s disease of the bone


Bone Resorption Inhibitors: Bisphosphonates: Adverse Reaction, Contraindications, Precautions

Bone Resorption Inhibitors: Bisphosphonates: Adverse Reaction, Contraindications, Precautions

• Adverse reactions:

– Nausea, diarrhea, increased or recurrent bone pain, headache, dyspepsia, acid regurgitation, dysphagia, abdominal pain

• Contraindications and precautions:

– Contraindicated in patients who are hypersensitive to the bisphosphonates

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– Alendronate, risedronate: Contraindicated in patients with hypocalcemia, during pregnancy

– Bisphosphonates: Contraindicated in patients with delayed esophageal emptying or renal impairment

– Used cautiously in patients with gastrointestinal disorders, renal function impairment

Bone Resorption Inhibitors: Bisphosphonates: Adverse Reaction, Contraindications, Precautions (cont 'd)

Bone Resorption Inhibitors: Bisphosphonates: Adverse Reaction, Contraindications, Precautions (cont 'd)

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Bone Resorption Inhibitors: Bisphosphonates: InteractionBone Resorption Inhibitors: Bisphosphonates: Interaction

Interactant drug Effect of interaction

Calcium supplements or antacids, with magnesium and aluminum

Decreased effectiveness of bisphosphonates

Aspirin Increased risk of GI bleeding

Theophylline Increased risk of theophylline toxicity


DMARD: Uses, Adverse ReactionsDMARD: Uses, Adverse Reactions

• Uses:

– Rheumatoid arthritis treatment: DMARDs are useful for their immunosuppressive ability

– Cancer therapy


– Nausea, stomatitis, alopecia

– Sulfa based drug- ocular changes, GI upset, and mild pancytopenia


DMARD: ContraindicationsDMARD: Contraindications

• Contraindications:

– In patients with known hypersensitivity to the drugs

– Methotrexate: Contradicted in patients with renal insufficiency, liver disease, alcohol abuse, pancytopenia, or folate deficiency

– Etanercept, adalimumab, and infliximab: Should not be used in patients with congestive heart failure or neurologic demyeliniating diseases



DMARD: Precautions and InteractionsDMARD: Precautions and Interactions• Precautions:In patients with obesity, diabetes,

and hepatitis B or C; Women should not become pregnant, sexual partners should use barrier contraception to prevent transmission of the drug via semen

• Interaction:Interactant Drug Effect of Interaction

Sulfa antibiotics Increased risk of methotrexate toxicity

Aspirin and NSAIDs Increased risk of methotrexate toxicity



Uric Acid Inhibitors: Uses and Adverse ReactionsUric Acid Inhibitors: Uses and Adverse Reactions• Uses:

– To manage acute attacks of gout; prevent acute attacks of gout


– Gastrointestinal reactions: Nausea, vomiting, diarrhea, abdominal pain

– Other Reactions: Headache, urinary frequency


Uric Acid Inhibitors: ContraindicationsUric Acid Inhibitors: Contraindications

• Contraindications: Patients with known hypersensitivity

– Sulfinpyrazone: Patients with peptic ulcer disease and GI inflammation

– Colchicine: Patients with serious GI, renal, hepatic, cardiac disorders, and those with blood dyscrasias

– Probenecid: Contraindicated in patients with blood dyscrasias, uric acid kidney stones, and in children younger than 2 years



Uric Acid Inhibitors: PrecautionsUric Acid Inhibitors: Precautions

• Precautions: Patients with renal impairment and during pregnancy

– Allopurinol: Used cautiously in patients with liver impairment

– Probenecid: Used cautiously in patients who are hypersensitive to sulfa drugs or patients who have peptic ulcer disease

– Colchicine: Used with caution in older adults



Uric Acid Inhibitors: InteractionsUric Acid Inhibitors: Interactions


Ampicillin Increased risk of rash

Theophylline Increased risk of theophylline toxicity

Aluminum-based antacids Decreased effectiveness of allopurinol

• Interactions: Allopurinol


Uric Acid Inhibitors: InteractionsUric Acid Inhibitors: Interactions


Penicillins, cephalosporins, acyclovir, rifampin, and the sulfonamides

Increased serum level of anti-infective

Barbiturates and benzodiazepines

Increased serum level of sedative

NSAIDs Increased serum level of NSAID

Salicylates Decreased effectiveness of probenecid

• Interactions: Probenecid


Uric Acid InhibitorsUric Acid Inhibitors


Oral anticoagulants Increased risk of bleeding

Tolbutamide Increased risk of hypoglycemia

Verapamil Increased effectiveness of verapamil

• Interactions: Sulfinpyrazone


Skeletal Muscle Relaxants: Uses and Adverse Reactions Skeletal Muscle Relaxants: Uses and Adverse Reactions • Uses:

– Various acute, painful musculoskeletal conditions


– Drowsiness: Most common reaction – Diazepam: Drowsiness, sedation,

sleepiness, lethargy, constipation or diarrhea, bradycardia or tachycardia, and rash


Skeletal Muscle Relaxants: ContraindicationsSkeletal Muscle Relaxants: Contraindications

– In patients with known hypersensitivity to the drugs

– Baclofen: Contraindicated in skeletal muscle spasms caused by rheumatic disorders

– Carisoprodol: Contraindicated in patients with a known hypersensitivity to meprobamate



Skeletal Muscle Relaxants: Contraindications (cont’d)Skeletal Muscle Relaxants: Contraindications (cont’d)

– Cyclobenzaprine: Contraindicated in patients with a recent myocardial infarction (MI), cardiac conduction disorders, and hyperthyroidism

– Oral dantrolene: Contraindicated during lactation and in patients with active hepatic disease and muscle spasm caused by rheumatic disorders

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Skeletal Muscle Relaxants: PrecautionsSkeletal Muscle Relaxants: Precautions• Precautions: Used with caution in patients with a

history of cerebrovascular accident, cerebral palsy, parkinsonism, or seizure disorders and during pregnancy and lactation

– Carisoprodol: Used with caution in patients with severe liver or kidney disease and during pregnancy and lactation

– Cyclobenzaprine: Used cautiously in patients with cardiovascular disease and during pregnancy and lactation

– Dantrolene - a pregnancy category C drug: Used with caution during pregnancy



Skeletal Muscle Relaxants: InteractionsSkeletal Muscle Relaxants: InteractionsInteractant drug Effect of interaction

CNS depressants, such as alcohol, antihistamines, opiates, and sedatives

Increased CNS depressant effect

Cyclobenzaprin :

MAOIs Risk for high fever and convulsions

Orphenadrine:

haloperidol Increased psychosis

Tizanidine:

Antihypertensives Increased risk of hypotension


Nursing Process: Assessment Nursing Process: Assessment

• Preadministration assessment:

– Obtain patient’s history - summary of the disorder, including onset, symptoms, and current treatment or therapy

– Examine affected joints in the extremities for appearance of the skin over the joint, evidence of joint deformity, and mobility of the affected joint if the patient has arthritis



Nursing Process: AssessmentNursing Process: Assessment

• Preadministration assessment (cont’d):

– Patient with gout: Examine the affected joints and notes the appearance of the skin over the joints and any joint enlargement

– Osteoporosis: Assessed for pain in upper and lower back or hip



Nursing Process: AssessmentNursing Process: Assessment

• Ongoing assessment:

– Inspect the joints involved every 1 to 2 hours to identify immediately a response or nonresponse to therapy

– Question the patients regarding relief of pain, adverse drug reactions

– Closely observe the patients for the development of adverse reactions



Nursing Process: PlanningNursing Process: Planning

• The expected outcome includes:

– Optimal response to therapy

– Support of patients needs related to the management of adverse reactions

– Understanding of and compliance with the prescribed therapeutic regimen

• Expected outcome: Depends on reason for the drug therapy



Nursing Process: Implementation Nursing Process: Implementation

• Promoting an optimal response to therapy:

– Be alert to reactions such as skin rash, fever, cough, or easy bruising

– Be attentive to specific patients complaints such as visual changes, tinnitus, or hearing loss

– Evaluate any complaint or comment made by the patients and report it to the primary health care provider



Nursing Process: ImplementationNursing Process: Implementation

• Promoting an optimal response to therapy (cont’d):

– Observe closely for development of adverse reactions, such as thrombocytopenia and leukopenia

– Immediately bring all adverse reactions or suspected adverse reactions to the attention of the primary health care provider



• Monitoring and managing patient needs:

– Readiness for enhanced fluid balance:

•Encourage a liberal fluid intake and measure the intake and output

– Impaired comfort: Gastric distress

•Administer the drug with 6 to 8 oz of water while the patient is in an upright position

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• Monitoring and managing patient needs (cont’d):

– Impaired comfort: Gastric distress (cont’d):

•Check the dosage and frequency carefully to prevent drug administration errors

•Administer DMARDs, uric acid inhibitors, and skeletal muscle relaxants with, or immediately after meals to minimize gastric distress




• Monitoring and managing patient needs (cont’d):

– Risk for injury:

•Evaluate the patient carefully before allowing the patient to ambulate alone

•Notify the primary health care provider before the next dose is due, if drowsiness is severe

•Assist with ambulatory activities if drowsiness does occur

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• Educating the patients and family:

– Develop an effective plan of patients and family teaching

– Explain that treatment for the disorder includes drug therapy, as well as other medical management

– Emphasize importance of not taking any nonprescription drugs unless their use has been approved by primary health care provider



Nursing Process: Evaluation Nursing Process: Evaluation

• The therapeutic drug effect is achieved

• Adverse reactions are identified, reported to the primary health care provider, and managed using appropriate nursing interventions

• The patient verbalizes the importance of complying with the prescribed therapeutic regimen

• The patient and family demonstrate an understanding of the drug regimen



End of Presentation

ppt chapter031

Health & Medicine

assessment preadministration assessment

skeletal muscle relaxants

lippincott williams

wilkins nursing process

adverse reaction

wilkins dmard

adverse reactions

renal impairment